1090 Amsterdam, 17th Floor New York, New York 10025 212-994-5100 Toll Free: 888-SLEEP-NY Fax: 212-994-5101 SLEEP DISORDERS INVENTORY Gary K. Zammit, Ph.D., Stephen Lund, M.D., Joseph Ghassibi, M.D., Kathleen Rice, Ph.D., & Jon Freeman, Ph.D. Instructions: Your responses to this questionnaire will offer your doctors a comprehensive overview of your sleep and sleep problems. In order to complete the questionnaire, you must respond to several fi ll-in-the-blank and forced-choice questions. Please answer all questions to the best of your ability, leaving no forced-choice item unanswered. Expect that the questionnaire will take you 15 to 20 minutes to complete. Follow the instructions on the last page to submit the questionnaire to your doctor or to Clinilabs for review. IDENTIFYING INFORMATION Today s Date / / Patient s Name Address Last First Middle City Home phone State ( ) Work phone ( ) Zip code Cellular phone ( ) E-mail Age D.O.B. / / Sex M F Marital Status (circle) S M D Height Weight Lbs. Neck Size inches. Your occupation: Your primary care physician: ( ) Name Address Telephone Specialist who referred you to the Sleep Disorders Institute (if applicable): ( ) Name Address Telephone Your referring doctor s area of specialty: Place and date(s) of prior evaluation(s) for sleep disorders (if any): Clinic or Hospital Clinic or Hospital Date / / Date / / 1
OVERVIEW OF SLEEP PROBLEMS 1. Why are you seeking treatment at this time? SLEEP ENVIRONMENT 2. Is there any aspect of your sleep environment that seems to contribute to your sleep problem? 3. Are you bothered by the lighting conditions of your bedroom during sleep? 4. Is your bedroom too hot or too cold during sleep? 5. Is your bedroom too humid or too dry? 6. Are you bothered by noise during sleep? 7. Is your bed or bedding uncomfortable? 8. Do you sleep with anyone else in the same room or the same bed? If yes, are you bothered by your roommate s or bed partner s snoring or movements during sleep? If yes, do you sleep in the same room or same bed with your children? 9. Do you sleep in the same bed with a pet? SLEEP HABITS 10. What is your usual bedtime (the time your get into bed)? 11. What is your usual rise time (the time you get out of bed)? 12. Does your bedtime and rise time fl uctuate from day to day? 13. Do you change your bedtime and rise time on the weekends or on days that you do not work? If yes, what is your usual bedtime on weekends or non-work days? If yes, what is your usual rise time on weekends or non-work days? 14. How long does it usually take you to fall asleep after you get into bed? mins 15. How many times do you usually awaken during the sleep period? times 16. What is the average duration of your awakenings? mins 17. On average, how long would you say you actually are asleep each night? hrs mins 18. Do you have a regular, nightly routine that you follow every night before getting into bed? If yes, what do you usually do? 2
19. Do you read, watch television, or engage in other activities while in bed before sleep onset? 20. Do you usually eat before getting into bed, or while in bed before sleep onset? 21. Do you tend to watch the clock before or during your sleep period? DAYTIME FUNCTIONING 22. Do you usually feel sluggish, sleepy, or fatigued upon awakening in the morning? 23. Do you usually feel fatigued throughout the day? 24. Are you bothered by low mood, irritability, or anxiety during the day? 25. Are you bothered by problems with attention, concentration, or memory during the day? 26. Do you fi nd it hard to persist at things you are doing, even simple things? 27. Do you have diffi culty functioning in social situations due to fatigue? 28 Do you have diffi culty functioning at work due to fatigue? 29. Are you usually bothered by sleepiness during the day? 30. Do you feel that you ve lost motivation to do things, or that you ve lost interest or pleasure in activities that you used to enjoy? 31. Has your sex drive (libido) diminished? 32. Have you been eating less than usual, or have you recently lost weight? 33. Have you been eating more than usual, or have you recently gained weight? 34. Do you tend to fall asleep in sedentary situations (for example, while watching television, working at a computer, in meetings)? 35. Do you fall asleep when in a warm room? 36. Do you tend to fall asleep at inappropriate times? If yes, please give an example: 37. Has your sleepiness or falling asleep ever put you or someone else in danger? 38. Have you had a motor vehicle accident due to sleepiness or fatigue? 39. Do you feel disabled by daytime sleepiness or fatigue? 40. Do you usually nap during the day? If : How long do you usually nap? minutes What time of day do you usually nap? Morning / Afternoon / Evening How many naps do you usually take per day? How many naps do you usually take per week? 3
DIFFICULTY FALLING ASLEEP AND STAYING ASLEEP 41. Do you usually have diffi culty falling asleep at the beginning of the sleep period? 42. Are you bothered by awakenings that occur during the night (after you ve fallen asleep)? 43. Do you wake up too early and fi nd that you can t return to sleep? 44. If you answered yes to any of the above, are you bothered by the problem? 45. Does diffi culty falling asleep or staying asleep interfere with your daytime functioning? SLEEP QUALITY 46. Are you bothered by restless or fi tful sleep? 47. Are you bothered by poor quality sleep? 48. Do you feel that you sleep too lightly? 49. Do you feel that your sleep is not restful, no matter how much sleep you get? SNORING AND DIFFICULTY BREATHING DURING SLEEP 50. Do you snore? 51. Have you been told that you snore loudly, or that your snoring disturbs others? 52. Have you awakened yourself or someone else with your snoring sounds? 53. Is snoring a source of distress in your marriage or other signifi cant relationship? 54. Has anyone ever told you that you seem to have diffi culty breathing or that you stop breathing during sleep? 55. Do you ever awaken with the sensation of shortness of breath? 56. Do you ever awaken gasping, choking, or gulping for air? 57. Do you often awaken with a dry mouth or sore throat? 58. Do you ever awaken feeling disoriented or confused? 59. Do you ever awaken with headaches? 60. Do you use the restroom frequently at night? 61. Do you experience acid refl ux, acid indigestion, or dyspepsia? 62. (Men) Do you have diffi culty getting or keeping an erection? 63. Have you had surgery for snoring or sleep apnea? 64. Have you been treated for snoring or sleep apnea with a dental device? 65. Have you been treated for snoring or sleep apnea with nasal CPAP, BiPAP, or Autopap? 4
NARCOLEPSY 66. Have you ever experienced sleep attacks (sudden, irresistible urge to sleep)? 67. Upon falling asleep or waking up have you ever had the experience of seeing things or hearing things that were not really there? 68. Upon falling asleep or waking up have you ever had the experience of being unable to Move your arms or legs, even if you try? 69. Have you ever done things during the day without having awareness of your actions? 70. Have you ever had a seizure? 71. Have you ever experienced sudden muscle weakness while awake (In mild conditions this could be experienced as a weak grip, or leg or arm weakness. In severe conditions, one s legs might buckle and the person might fall to the fl oor)? If yes, was this brought on by an intense emotion? 72. Do you start dreaming right after you fall asleep? SLEEP AND SLEEP-RELATED MOVEMENTS 73. Do you experience painful or unusual sensations of your legs while at rest, especially in the evening? 74. Do painful or unusual sensations of your legs interfere with your ability to fall asleep? 75. Do you experience painful or unusual sensation of your legs that awaken you, or that prevent you from returning to sleep if you wake up during your sleep period? 76. If you answered yes to any of the above items, does walking or massage seem to relieve the discomfort in your legs? 77. Do you ever experience twitching or jerking of your feet or legs while asleep? 78. Do your leg movements disturb your bed partner? 79. Do you notice that your hands and feet are cold prior to, during, or after sleep? SLEEP RHYTHMS 80. If employed, what are your usual work hours? Start shift: End: 81. Are you a shift worker (evenings, nights, or rotating shifts)? 82. Do you struggle to balance your shift work and family activities? 83. Do you suffer from jet lag? 84. Do you fi nd that you typically fall asleep earlier than desired and awaken earlier than desired? 85. Do you fi nd that you typically fall asleep later than desired and awaken later than desired? 5
PARASOMNIAS 86. Please indicate if you have experienced the following symptoms at any time. Please note the age that symptoms began and your age when they stopped. Place a checkmark in the column at the right to indicate an ongoing problem. Problem Behavior Sleepwalking Check yes if past or current problem Frequency/ week Age when symptoms began If stopped, age when last occurred Ongoing problem? Sleepwalking associated with night eating Sleepwalking associated with injury to self/others Nightmares Night Terrors Bed Wetting Diffi culty swallowing during sleep Sudden unusual movements during sleep Sleep talking Other (describe): MEDICAL STATUS AND HISTORY 87. Have you now, or have you ever in the past, received treatment for high blood pressure? 88. Have you been told that you have an irregular heartbeat (cardiac arrhythmia)? 89. Have you ever suffered a stroke? 90. Have you ever sufferered a heart attack? 91. Have you been told that you have GERD (gastroesophageal refl ux disease), acid indigestion, or dyspepsia? If yes, why? 92. Have you ever been hospitalized for any reason? 93. Have you ever had surgery? If yes, why? 94. Have you ever had a serious injury? If yes, why? 6
95. Please complete the following checklist by identifying medical conditions that you have now or have had in the past: System Type of problem Date problem began Head, eyes, ears se Sinuses Mouth and throat Lungs and chest (COPD) Ongoing or indicate date stopped Heart (Heart attack, high blood pressure) Central nervous system (e.g., headaches, seizures) Digestive system (e.g., GERD) Musculoskeletal system Endocrine system (e.g., overweight, diabetes, etc.) Skin Allergies (specify to what) Psychiatric Other MEDICATION USE 96. Please list all prescription and over-the-counter medications that you currently use. Medication Name Dose (if known) Number Pills Taken per Day (if use is less than daily please indicate frequency of use) Reason Used Check Here if Medication is Used to Treat a Sleep Problem Effectiveness Prescribing Doctor FOOD, BEVERAGES AND OTHER SUBSTANCES 97. For each beverage listed, indicate the average number of ounces you drink per day: Regular coffee Regular tea Cola 98. Do you usually drink caffeinated beverages (coffee, tea, cola) within 6 hours before bedtime? 7
99. Do you drink caffeinated beverages during the day to help you stay awake? 100. On average, do you consume more than 5 alcoholic drinks per day? 101. On average, do you consume more than 15 alcoholic drinks per week? 102. Do you drink alcohol (beer, wine, or hard liquor) shortly before bedtime? 103. Do you use alcohol to help you fall asleep? 104. Do you smoke cigarettes? If yes, how many cigarettes do you smoke per day? Do you smoke just before bed, or if you happen to awaken during your sleep period? 105. Do you smoke cigars or a pipe? 106. Do you use any illicit drugs (e.g., marijuana, cocaine, crack)? 107. Do you use any illicit drugs to help you fall asleep or stay asleep, or stay awake? FAMILY AND SOCIAL HISTORY 108. 109. 110. Father s age: Mother s age: Number of siblings: If deceased, what was the year and cause of death? If deceased, what was the year and cause of death? Ages of your children: 111. Does anyone in your family have any sleep problems? If so, briefl y describe and give their relationship to you: 112. Does anyone in your family have a history of serious medical or psychiatric problems? If so, what is their problem and what is their relationship to you? 113. Is there any additional information regarding your sleep, medical, or family histories that you would like to add? Thank you for completing the Sleep Disorders Inventory. The information that you have provided will assist your doctor in evaluating and treating your sleep complaint. If you have completed this questionnaire in your primary care doctor s or specialist s offi ce, you should review your answers with the doctor. You also may ask your doctor to submit your questionnaire to the Clinilabs Sleep Disorders Institute for review. Please use the e-mail or the street address indicated below for all correspondence. If you have completed this questionnaire at the Sleep Disorders Institute, you may request a copy for your fi les or your doctor s medical record. Your health is our fi rst concern. For more information about sleep and sleep disorders, please visit www.sleepfacts.com. For more information about Clinilabs and its affi liates, you may visit our corporate Web site at www.clinilabs.com. Please submit inquiries to info@clinilabs.com. Please return all completed questionnaires to: Clinilabs, Inc. Sleep Disorders Institute 1090 Amsterdam Avenue, 17th Floor New York, New York 10025 Tel: 212-994-5100 Fax: 212-994-5101 E-mail: info@clinilabs.com www.clinilabs.com Clinilabs, Inc. All Rights Reserved. 8